Scott\'s Notes - Surgery 2012 v2 PDF

Preview

Summary

surgery summary of Oxford handbook...

Description

Surgery 2012 v2 Alasdair Scott BSc (Hons) MBBS MRCS PhD

2018 [email protected] www.scottsnotes.co.uk

© Alasdair Scott, 2018

© Alasdair Scott, 2018

Table of Contents 1. Perioperative Management ..................................................................................... 1 2. Fluids and Nutrition ...............................................................................................11 3. Trauma .................................................................................................................. 17 4. Upper GI Surgery .................................................................................................. 25 5. Hepatobiliary Surgery ............................................................................................ 35 6. Lower GI Surgery .................................................................................................. 43 7. Perianal Surgery .................................................................................................... 59 8. Hernias .................................................................................................................. 65 9. Superficial Lesions ................................................................................................ 70 10. Breast Surgery .................................................................................................... 81 11. Vascular Surgery ................................................................................................. 86 12. Urology ................................................................................................................ 95 13. Orthopaedics ..................................................................................................... 110 14. Ear, Nose and Throat ........................................................................................ 132 15. Ophthalmology .................................................................................................. 145

i

© Alasdair Scott, 2018

© Alasdair Scott, 2018

Perioperative Management Contents Pre-Operative Assessment and Planning .............................................................................................................. 2! Specific Pre-operative Complications .................................................................................................................... 3! Anaesthesia ........................................................................................................................................................... 4! Analgesia ............................................................................................................................................................... 4! Enhanced Recovery After Surgery ........................................................................................................................ 5! Surgical Complications .......................................................................................................................................... 5! Post-op Complications: General ............................................................................................................................ 6! Post-op Complications: Specific ............................................................................................................................ 7! Post-op Pyrexia...................................................................................................................................................... 8! Deep Venous Thrombosis ..................................................................................................................................... 9! Other Common Post-Operative Presentations .................................................................................................... 10!

1

© Alasdair Scott, 2018

Pre-Operative Assessment and Planning Aims • • • •

Preparation Informed consent Assess risk vs. benefits Optimise fitness of patient Check anaesthesia / analgesia type ¯c anaesthetist

NBM •

≥2h for clear fluids, ≥6h for solids

Bowel Prep •

Pre-op Checks: OP CHECS • • • •

• • •

Operative fitness: cardiorespiratory comorbidities Pills Consent History § MI, asthma, HTN, jaundice § Complications of anaesthesia: DVT, anaphylaxis Ease of intubation: neck arthritis, dentures, loose teeth Clexane: DVT prophylaxis Site: correct and marked

• •

Prophylactic Abx •

Drugs Anti-coagulants • Balance risk of haemorrhage ¯c risk of thrombosis • Avoid epidural, spinal and regional blocks

• •

AED • •

May be needed in left-sided ops § Picolax: picosulfate and Mg citrate § Klean-Prep: macrogol Not usually needed in right-sided procedures Necessity is controversial as benefit of minimising post-op infection might not outweigh risks § Liquid bowel contents spilled during surgery § Electrolyte disturbance § Dehydration § ↑ rate of post-op anastomotic leak

Use § GI surgery (20% post-op infection if elective) § Joint replacement Give 15-60min before surgery Regimens: (see local guidelines) § Biliary: Cef 1.5g + Met 500mg IV § CR or appendicetomy: Cef+Met TDS § Vascular: co-amoxiclav 1.2g IV TDS § MRSA+ve: vancomycin

Give as usual Post-op give IV or via NGT if unable to tolerate orally

DVT Prophylaxis OCP / HRT • •

•

Stop 4wks before major / leg surgery Restart 2wks post-op if mobile

• • •

β-Blockers •

Continue as usual • •

Pre-op Investigations Bloods • •

•

Routine: FBC, U+E, G+S, clotting, glucose Specific § LFTs: liver disease, EtOH, jaundice § TFT: thyroid disease § Se electrophoresis: Africa, West Indies, Med Cross-match § Gastrectomy: 4u § AAA: 6u

Stratify pts according to patient factors and type of surgery. Low risk: early mobilisation Med: early mobilisation + TEDS + 20mg enoxaparin High: early mobilisation + TEDS + 40mg enoxaparin + intermittent compression boots perioperatively. Prophylaxis started @ 1800 post-op May continue medical prophylaxis at home (up to 1mo)

ASA Grades • • • • •

Normally healthy Mild systemic disease Severe systemic disease that limits activity Systemic disease which is a constant threat to life Moribund: not expected to survive 24h even¯cop

Cardiopulmonary Function • • • • •

CXR: cardiorespiratory disease/symptoms, >65yrs Echo: poor LV function, Ix murmurs ECG: HTN, Hx of cardiac disease, >55yrs Cardiopulmonary Exercise Testing PFT: known pulmonary disease or obesity

Other • •

Lat C-spine flexion and extension views: RA, AS MRSA swabs

2

© Alasdair Scott, 2018

Specific Pre-operative Complications Jaundice

Diabetes

• •

↑ Risk of post-operative complications • • • •

Surgery → stress hormones → antagonise insulin Pts. are NBM ↑ risk of infection IHD and PVD

• • •

Dipstick: proteinuria Venous glucose + U+E: K

• • • • •

Practical Points

• •

•

Pts. ¯c obstructive jaundice have ↑ risk of post-op renal failure \ need to maintain good UO. Coagulopathy ↑ infection risk: may → cholangitis

Pre-op

IDDM •

Risks

• •

Pre-op

Best to avoid operating in jaundiced pts. Use ERCP instead

Put pt. first on list and inform surgeon and anaesthetist Some centres prefer to use GKI infusions Sliding scale may not be necessary for minor ops § If in doubt, liaise ¯c diabetes specialist nurse

Avoid morphine in pre-med Check clotting and consider pre-op vitamin K Give 1L NS pre-op (unless CCF) → moderate diuresis Urinary catheter to monitor UPO Abx prophylaxis: e.g. cef+met

Intra-op • •

Hrly UO monitoring NS titrated to output

Post-op Insulin • • •

• •

± stop long-acting insulin the night before Omit AM insulin if surgery is in the morning Start sliding scale § 5% Dex ¯c 20mmol KCl 125ml/hr § Infusion pump ¯c 50u actrapid § Check CPG hrly and adjust insulin rate Check glucose hrly: aim for 7-11mM Post-op § Continue sliding-scale until tolerating food § Switch to SC regimen around a meal

• •

Anticoagulated Patients • • • • •

NIDDM • • • •

If glucose control poor (fasting >10mM): treat as IDDM Omit oral hypoglycaemics on the AM of surgery Eating post-op: resume oral hypoglycaemics¯c meal No eating post-op § Check fasting glucose on AM of surgery § Start insulin sliding scale § Consult specialist team ore. restarting PO Rx

Balance risk of haemorrhage ¯c risk of thrombosis Consult surgeon, anaesthetist and haematologist Very minor surgery may be undertaken w/o stopping warfarin if INR 24h post-op § Usually due to infection

5-7d post-op Organisms: S. aureus and Coliforms

Operative Classification • • • •

Clean: incise uninfected skin w/o opening viscus Clean/Cont: intra-op breach of viscus (not colon) Contaminated: breach of viscus + spillage or opening of colon Dirty: site already contaminated – faeces, pus, trauma

Risk Factors

Post-op Urinary Retention

•

Causes • • •

Drugs: opioids, epidural/spinal, anti-AChM Pain: sympathetic activation → sphincter contraction Psychogenic: hospital environment

•

Risk Factors • • • • •

Male ↑ age Neuropathy: e.g. DM, EtOH BPH Surgery type: hernia and anorectal

•

Conservative § Privacy § Ambulation § Void to running taps or in hot bath § Analgesia Catheterise ± gent 2.5mg/kg IV stat TWOC = Trial w/o Catheter § If failed, may be sent home ¯c silicone catheter and urology outpt. f/up.

•

Mx • • •

Mx

• •

Presentation • •

Occurs after every nearly every GA Mucus plugging + absorption of distal air → collapse •

Causes

•

Pre-op smoking Anaesthetics ↑ mucus production ↓ mucociliary clearance Pain inhibits respiratory excursion and cough

•

Presentation • • • •

w/i first 48hrs Mild pyrexia Dyspnoea Dull bases ¯c ↓AE

• •

Good analgesia to aid coughing Chest physiotherapy

Mx

Occurs ~10d post-op Preceded by serosanguinous discharge from wound

Risk Factors

Pulmonary Atelectasis

• •

Regular wound dressing Abx Abscess drainage

Wound Dehiscence

•

• •

Pre-operative § ↑ Age § Comorbidities: e.g. DM § Pre-existing infection: e.g. appendix perforation § Pt. colonisation: e.g. nasal MRSA Operative § Op classification and wound infection risk § Duration § Technical: pre-op Abx, asepsis Post-operative § Contamination of wound from staff

Pre-Operative Factors § ↑ age § Smoking § Obesity, malnutrition, cachexia § Comorbs: e.g. BM, uraemia, chronic cough, Ca § Drugs: steroids, chemo, radio Operative Factors § Length and orientation of incision § Closure technique: follow Jenkin’s Rule § Suture material Post-operative Factors § ↑ IAP: e.g. prolonged ileus → distension § Infection § Haematoma / seroma formation

Mx • • • • •

•

Replace abdo contents and cover¯c sterile soaked gauze IV Abx: cef+met Opioid analgesia Call senior and arrange theatre Repair in theatre § Wash bowel § Debride wound edges § Close ¯ c deep non-absorbable sutures (e.g. nylon) May require VAC dressing or grafting

6

© Alasdair Scott, 2018

Post-op Complications: Specific General Surgery

Vascular

Cholecystectomy

Arterial Surgery

• • • • •

• • •

Conversion to open: 5% CBD injury: 0.3% Bile leak Retained stones (needing ERCP) Fat intolerance / loose stools

Aortic Surgery

Inguinal Hernia Repair • • • • • •

Early Haematoma / seroma formation: 10% Intra-abdominal injury (lap) Infection: 1% Urinary retention Late § Recurrence: 0.5% § Ischaemic orchitis: 0.5% § Chronic groin pain / paraesthesia: 10-20%

Abscess formation Fallopian tube trauma Right hemicolectomy (e.g. for carcinoid, caecal necrosis)

Colonic Surgery •

•

Early § § § § Late § §

• • • • •

Breast • • •

Ileus Anastomotic leak Enterocutaneous fistulae Abdominal or pelvic abscess

• •

•

•

Causes § Bowel handling § Anaesthesia § Electrolyte imbalance Presentation § Distension § Constipation ± vomiting § Absent bowel sounds Rx § IV fluids + NGT § TPN if prolonged

• • • •

ENT • •

• •

• • •

Wound haematoma → tracheal obstruction Recurrent laryngeal N. trauma → hoarse voice § Transient in 1.5% § Permanent in 0.5% § R commonest (more medial) Hypoparathyroidism → hypocalcaemia Thyroid storm Hypothyroidism

Tracheostomy • • •

Stenosis Mediastinitis Surgical emphysema

Orthopaedic Surgery • • • •

Short gut syndrome (≤250cm)

Splenectomy •

Urinary incontinence Erectile dysfunction Retrograde ejaculation Prostatitis

Fracture Repair

Anal incontinence Stenosis Anal fissure

Small Bowel Surgery •

Sepsis Uroma: extravasation of urine

Thyroidectomy Adhesions → obstruction Incisional hernia

Anorectal Surgery • • •

Arm lymphoedema Skin necrosis Seroma

Prostatectomy

Post-op Ileus •

Gut ischaemia Renal failure Aorto-enteric fistula Anterior spinal syndrome (paraplegia) Emboli → distal ischaemia (trash foot)

Urological

Appendicectomy • • •

Thrombosis and embolisation Anastomotic leak Graft infection

O

Gastric dilatation (2 gastric ileus) § Prevent ¯c NGT Thrombocytosis → VTE Infection: encapsulated organisms

Mal-/non-union Osteomyelitis Avascular necrosis Compartment syndrome

Hip Replacement • • • • •

Deep infection VTE Dislocation Nerve injury: sciatic, SGN Leg length discrepancy

Cardiothoracic Surgery • •

Pneumo-/haemo-thorax Infection: mediastinitis, empyema

7

© Alasdair Scott, 2018

Post-op Pyrexia Causes

Pneumonia

Early: 0-5d post-op

Cause

• • • • •

Blood transfusion O Physiological: SIRS 2 to trauma, 0-1d Pulmonary atelectasis: 24-48hrs Infection: UTI, superficial thrombophlebitis, cellulitis Drug reaction

Pneumonia VTE: 5-10d Wound infection: 5-7d Anastomotic leak: 7d Collection: 5-20d

Anaesthesia → atelectasis Pain → ↓ cough Surgery → immunosuppression

• • •

Chest physio: encouraging coughing Good analgesia Abx

Rx

Delayed: >5d post-op • • • • •

• • •

Collection Presentation • • • •

Examination of Post-Op Febrile Pt. • • • • • • • •

Observation chart, notes and drug chart Wound Abdo + DRE Legs Chest Lines Urine Stool

• • • •

Urine: dip + MCS Blood: FBC, CRP, cultures ± LFTs Cultures: wound swabs, CVP tip for culture CXR

Malaise Swinging fever, rigors Localised peritonitis Shoulder tip pain (if subphrenic)

Locations • • • • • •

Pelvic Subphrenic Paracolic gutters Lesser sac Hepatorenal recess (Morrison’s space) Small bowel (interloop spaces)

• • •

FBC, CRP, cultures US, CT Diagnostic lap

• •

Abx Drainage / washout

Ix Ix

Rx

Cellulitis •

Acute infection of the subcutaneous connective tissue

Cause: β-haemolytic Streps + staph. aureus Presentation • • •

Pain, swelling, erythema and warmth Systemic upset ± lymphadenopathy

• •

Benpen IV Pen V and fluclox PO

Rx

8

© Alasdair Scott, 2018

Deep Venous Thrombosis Epidemiology •

Preventing DVT

DVTs occur in 25-50% of surgical patients without thromboprophylaxis

Risk Factors: Virchow’s Triad •

•

•

Blood Contents § Surgery → ↑ plats and ↑ fibrinogen § Dehydration § Malignancy § Age: ↑ Blood Flow § Surgery § Immobility § Obesity Vessel Wall § Damage to veins: esp. pelvic veins § Previous VTE

Signs • • • • •

Peak incidence @ 5-10d post-op 65% of below knee DVTs are asymptomatic Calf warmth, tenderness, erythema, swelling Mild pyrexia Pitting oedema

Pre-Op • • • •

Pre-op VTE risk assessment TED stockings Aggressive optimisation: esp. hydration Stop OCP 4wks pre-op

Intra-Op • • •

Minimise length of surgery Use minimal access surgery where possible Intermittent pneumatic compression boots

Post-Op • • • • •

LMWH Early mobilisation Good analgesia Physio Adequate hydration

Differential • •

Cellulitis Ruptured Baker’s cyst

• • •

D-Dimers: sensitive but not specific Compression US (clot will be incompressible) Thrombophilia screen if: § No precipitating factors § Recurrent DVT § Family Hx

• •

Assess probability using Wells’ Score Low-probability → perform D-dimers § Negative → excludes DVT § Positive → Compression US Med / High probability → Compression US

Ix

Dx

•

Rx Anticoagulate • • • •

Therapeutic LMWH: enoxaparin 1.5mg/kg/24h SC Start warfarin using Tait model: 5mg OD for first 4d Stop LMWH when INR 2.5 Duration

§ Below knee: 6-12wks § Above knee: 3-6mo § On-going cause: indefinite

Graduated Compression Stockings •

Consider for prevention of post-phlebitic syndrome

9

© Alasdair Scott, 2018

Other Common Post-Operative Presentations Dyspnoea / Hypoxia

Hypotension

Causes

Immediate Mx

• • • • • •

Previous lung disease Atelectasis, aspiration, pneumonia LVF PE Pneumothorax (e.g. due to CVP line insertion) Pain → hypoventilation

• • •

FBC, ABG CXR ECG

• •

Sit up, give O2, monitor SpO2 Rx cause

• •

Tilt bed head down, give O2 Assess fluid status

Causes: CHOD •

•

Ix

• •

Rx

Cardiogenic § MI § Fluid overload Hypovolaemia § Inadequate replacement of fluid losses § Haemorrhage Obstructive § PE Distributive § Sepsis § Neurogenic shock

Mx •

Reduced Urine Output

• • • •

Causes •

• • • •

Post-renal § Commonest cause § Blocked / malsited catheter § Acute urinary retention Pre-renal: hypovolaemia Renal: NSAIDs, gentamicin Anuria usually = blocked or malsited catheter Oliguria usually = inadequate fluid replacement

Hypovolaemia → fluid challenge § 250-500ml colloid over 15-30min Haemorrhage → return to theatre Sepsis → fluid challenge, start Abx Overload → frusemide Neurogenic → NA infusion

Hypertension •

Continue anti-hypertensives during peri-operative period

Causes

Mx •

•

•

Information § Op Hx § Obs chart: UO § Drug chart: nephrot...